With the recent implementation of a combined inpatient/outpatient FLS (Fracture Liaison Service) at the Queen Elizabeth Hospital (QEH) in Charlottetown, PEI becomes the very first province in Canada where FLS is available for every resident who suffers a fragility fracture of the hip, wrist, shoulder or pelvis.
This quality improvement program focuses on secondary fracture prevention by identifying patients at risk for future fracture and initiating appropriate evaluation, risk assessment, education, and therapeutic intervention. From inception, data collection and analysis have been central to the program, and approval by the Research Ethics Board was obtained to permit the publication of quality assurance data. The program undergoes regular iterative program modifications based on evolving risk assessment tools and treatment guidelines, performance outcomes, and qualitative study results.
It is important to spend the time needed to determine the most appropriate professional background for your new FLS coordinator and this will largely depend on your local individual context. Nursing offers by far the best fit in terms of scope of practice. But should you hire an RN or an NP? This article aims to cover some of the important considerations.
Dr. Famida Jiwa, President & CEO, Osteoporosis Canada is pleased to announce that Dr. Earl Bogoch has been appointed the inaugural holder of the Brookfield Chair in Fracture Prevention. This University of Toronto chair, a global first of its type, has been established at the University of Toronto and St. Michael’s Foundation through the generosity of Brookfield Partners Foundation, which provided a $3 million grant. Dr. Bogoch was appointed after a Faculty search process.
My grandmother’s broken hip was never repaired thus her last 7 years of life consisted of lying in her bed in a long-term care home. Her life was fractured as well as her family’s as they supported her through her final years. For Grammie, her fracture meant leaving the family home with its wide veranda next door to her kids and entering “the Mount”. Now family visits consisted of cramming into a dim, shared room with interruptions by staff and other residents all while trying to avert your eyes from Grammie’s misaligned leg under the covers, her increasing dementia and her institutional existence.
FLS Coordinators are no strangers to finding innovative methods to improve care for their patients. With the goal of ensuring that every fragility fracture patient is provided appropriate osteoporosis care, FLS Coordinators have often been successful at finding creative solutions when they identify significant barriers in care.
The Covid-19 pandemic has had a major impact on healthcare services and FLSs have not been immune. Many FLSs across the country have been temporarily suspended as their staff was redeployed to pandemic efforts. Of those FLSs which remained operational, the FLS coordinators had to quickly adapt to the marked reduction (or total lack thereof) of other osteoporosis services such as BMD testing.
With dedication and innovation, FLS coordinators across Canada have faced this new challenge head on and have helped minimize the negative impacts of the pandemic on their fragility fracture patients. Shannon Falsetti is the FLS coordinator at the Misericordia Community Hospital in Edmonton, Alberta. She indicates: “When our site was closed due to an outbreak, I was able to seamlessly work from home and complete virtual follow ups. Our IT department made sure I had appropriate access while still maintaining privacy and documentation policies”.
Lack of access to BMD testing was of course a major consequence of the pandemic across this country. FLS coordinators worked with Diagnostic Imaging services to facilitate rescheduling of many BMD tests that had to be cancelled.
Ensuring that high risk patients are initiated and/or continued on the urgently needed osteoporosis treatment is always a priority for FLS coordinators. For many patients on parenteral osteoporosis treatment, this posed some new and unexpected challenges as many of them were fearful of leaving their homes. FLS coordinators helped find solutions for them which included coordinating a switch to an oral therapeutic option, arranging for local pharmacists to administer their injection or, in certain cases, helping patients learn how to self-inject using virtual communication tools.
In these times of uncertainty, some patients needed reassurances and coordinators were able to explore fears and feelings with their patients and family. They also took this time to review the importance of fracture risk, share information regarding local public health recommendations and to determine some safety strategies to minimize the risk of Covid-19 exposure (e.g. home collections for lab work, home care or pharmacy delivery).
The goal for every FLS program is to identify fragility fracture patients, investigate the patient’s risk of future fractures, and initiate prescription therapy for those at high risk. With many FLSs now resuming this important work, fragility fracture patients who have access to an FLS are truly lucky to have such dedicated healthcare professionals providing them with the care they need to help them prevent future fractures.
A province-wide post fracture care gap has previously been documented in Nova Scotia: in 2010, only 23% of hip fracture patients received osteoporosis medication within 6 months of their fracture.1
With the assistance of the Dartmouth General Hospital (DGH) Foundation and a philanthropic grant from Sun Life Financial, the first Nova Scotia (NS) FLS was implemented at the DGH in February of 2013. The DGH FLS proved its effectiveness at the end of its first year with 79% of the hip fracture patients and 81% of the total high risk patients receiving a first line osteoporosis medication within 6 months of fracture (excluding patients lost to follow-up).2
With proof of concept established, the DGH FLS model became the prototype for future NS FLSs. Embracing clinically-effective and value-based innovations, the Nova Scotia Department of Health and Wellness and the Nova Scotia Health Authority (NSHA) proceeded to staged expansion of FLS within the province, with implementation of new FLSs at the Valley Regional Hospital in Kentville in 2016 and at the Cape Breton Regional Hospital in Sydney in 2017. Currently, three of the province’s five orthopaedic centres operate an FLS for fragility fracture patients presenting to inpatient and outpatient orthopaedic services.
The NSHA FLS program is administered by Primary Health Care. A critical priority of the NS FLS is to integrate the patient’s osteoporosis care with their primary care provider (PCP). As these patients’ fracture risk is high and imminent, the goal is to facilitate urgent initiation of osteoporosis treatment for those who need it. Communication with the patient’s PCP is initiated at the FLS nurse’s very first interaction with the fracture patient. The FLS nurse coordinates all of the required investigations. A comprehensive report including the results of all investigations, the patient’s fracture risk by FRAX and recommendations specific to the patient’s fracture risk as per OC’s clinical practice guidelines is provided to the PCP. As all of the required information is conveniently in the PCP’s hands, initiation of the urgently needed treatment is expedited. Additionally, the FLS nurse will follow the patient for one year, to help monitor adherence to osteoporosis treatment and to respond to their frequent questions and concerns.
As with all effective FLSs, the NS FLSs ensure they optimize patient outcomes with a continuous quality improvement process in place. They participated in Osteoporosis Canada’s first national FLS audit for the 6-month cohort of patients enrolled April 1-September 30, 2017.3 During that timeframe, 347 NS patients were enrolled in the FLSs. In NSHA FLSs, 42.7% of the patients with fragility fracture were identified (first i) compared to national average of 57%. Fracture risk was completed (second i) in 92.5% (national average 89%). Treatment initiation (third i) in high risk patients was 52.4% (national average 49%).
Participation in that national FLS audit was most informative for the NS FLSs. The first i was noted to be Nova Scotia’s biggest area for improvement. Upon further exploration, one of the NSHA FLS exclusion criteria, patients without a primary care provider (PCP), was identified as the main barrier: patients without PCP were 15.1%, 11.4% and 6.8% respectively in Dartmouth, Kentville and Sydney. As a result of this audit, NSHA’s FLS Care Directive has now been updated to include those patients without PCP. NS FLSs will be participating in OC’s second national FLS audit and are hoping to see improved results. All of the FLSs in Nova Scotia are committed to continuous quality improvement to ensure that they are meeting the needs of fragility fracture patients.
- Nova Scotia: Department of Health and Wellness. Acute and Chronic Disease Target Setting Project – Summary Report; 2012.
- Thériault D, Purcell C. A Fracture Liaison Service specifically designed to address local government concerns can be effective. Journal of Bone and Mineral Research, 2014;(Suppl. 1).
- Theriault D, Purcell C, Griffin G, Pimentel B. NSHA Fracture Liaison Services (FLS): improving osteoporosis care for patients with fragility fractures. Primary Healthcare Research Day 2019, Halifax.